What are the initial steps for a sepsis screen?

Sepsis Screening Protocol

A comprehensive sepsis screening protocol includes obtaining blood cultures, measuring serum lactate, and applying clinical screening tools like qSOFA or SIRS criteria to identify patients with suspected infection who may have sepsis. 1

Initial Screening Steps

Clinical Assessment

• Apply quick Sequential Organ Failure Assessment (qSOFA) for rapid bedside assessment 1:

  • Altered mental status
  • Respiratory rate ≥22 breaths/min
  • Systolic blood pressure ≤100 mmHg

• Alternative screening with Systemic Inflammatory Response Syndrome (SIRS) criteria 2, 1:

  • Temperature >38°C or <36°C
  • Heart rate >90 beats/min
  • Respiratory rate >20 breaths/min
  • White blood cell count >12,000/mm³ or <4,000/mm³ or >10% immature bands

Laboratory Testing

• Obtain blood cultures (at least 2 sets - aerobic and anaerobic) before starting antimicrobial therapy 2, 1
• Measure serum lactate level immediately 1, 3
  • Lactate ≥2.0 mmol/L requires immediate physician notification 3
  • Lactate ≥4.0 mmol/L indicates severe sepsis with higher mortality risk 4
• Collect appropriate cultures from suspected infection sites (urine, wound, respiratory, etc.) 1

Additional Diagnostic Testing

• Complete blood count with differential
• Comprehensive metabolic panel
• Coagulation studies
• Imaging studies to identify potential infection source 2
• Consider specialized tests based on suspected source:
  • 1,3-β-D-glucan assay or mannan/anti-mannan antibody tests if fungal infection suspected 2

Risk Stratification and Monitoring

• Use NEWS2 score to determine risk of severe illness or death 1

• Monitor vital signs frequently, including:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation
  • Urine output (target ≥0.5 mL/kg/hr) 2

• Consider combining screening tools for better accuracy:

  • qSOFA + lactate measurement significantly improves sensitivity (87.5%) and specificity (81.4%) 5

Response to Positive Screen

When sepsis is identified, immediately initiate the 3-hour bundle 2, 1:

1. Administer broad-spectrum antibiotics within 1 hour of recognition 2, 1
2. Begin fluid resuscitation with at least 30 mL/kg of IV crystalloid fluids 2, 1
3. Reassess hemodynamic status frequently 2
4. Target mean arterial pressure ≥65 mmHg 2
5. If lactate is elevated, repeat measurement within 6 hours 2

Special Considerations

• In maternal sepsis, use obstetric-modified SIRS criteria during pregnancy and up to 3 days postpartum 2
• For immunocompromised patients, maintain a lower threshold for sepsis screening 1
• Consider early critical care consultation for patients with positive screens 2

Pitfalls to Avoid

• Delayed recognition: Don't wait for all criteria to be present before initiating screening and treatment 1
• Overreliance on single tools: qSOFA alone has limited sensitivity; combine with other assessments 5
• Delaying antibiotics: Never delay antimicrobial therapy for culture collection if it would cause >45 minutes delay 2
• Inadequate source control: Identify and address the infection source promptly 1
• Incomplete monitoring: Continue reassessment after initial interventions 2, 1

Early identification and treatment of sepsis significantly reduces mortality. The combination of clinical screening tools with laboratory markers like lactate provides the most effective approach to sepsis screening and early intervention.